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Spotlight on headaches

As recommendations on how GPs should diagnose and manage patients' headaches are published, experts explain why more than 10 million people in the UK experience them and how to tell whether they're
a sign of something more serious.

By Lisa Salmon.

If your headaches are bad enough for you to visit your doctor, chances are you're worried that something serious may be causing them.

Being sent home after a short consultation with a paracetamol will probably leave you more anxious than you were before - especially if the pains persist.

But headaches are one of the most common health complaints and, though they may be painful and distressing, the majority of the time, they aren't life-threatening.

That's not to say they're not a serious medical disorder - not only in terms of coping with the symptoms, but the anxiety that comes with it.

"The ones who do, don't have a particularly satisfying experience," he says.

"There are a variety of potential providers for headache treatment, but they're not always addressing the needs of patients.

"Benign headaches can be hugely debilitating and really affect the quality of your life, but if they're properly diagnosed, that can be turned around."

This is one of the aims of new draft guidelines by the National Institute for Health and Clinical Excellence (NICE), addressing how GPs and other general doctors diagnose and manage most patients'
headaches.

Published later this year, the guidelines relate to the three most common types of primary headache (i.e. those not caused by underlying health concerns) - tension headaches, migraine and cluster
headaches - which account for the vast majority of headaches that people visit their GPs about.

The aim is to improve communication between patient and doctor so that anybody visiting their GP will be given a clear, positive diagnosis and options for managing the symptoms will be discussed.

If patients understand what's causing their symptoms, they'll be less likely to go home worrying that they may have a brain tumour and distressed that they're being ignored.

"Concerns about the possible underlying causes need to be appropriately managed," says Professor Mark Baker, director of the Centre for Clinical Practice at NICE.

He stresses that patients need reassurance that other possible causes have been considered and excluded.

However, this doesn't mean everybody should be referred for scans. Professor Baker points out that unnecessary investigations can actually lead to "delays in people receiving adequate pain relief
for what can be an extremely disabling condition".

The guidelines advise that people need only be referred for scans if they have one or more extra features, such as a change in personality or recent head trauma.

Worried patients will often keep returning to their GP until they are referred for one, as shown in a 2005 Kings College study.

"It might be more cost-effective to go ahead and do the scan," Dr Dowson suggests.

"But a scan might not be the best answer - the best answer is to assess the patient and have a proper dialogue with them."

He explains that many of the serious causes of headaches, such as brain haemorrhages or meningitis, are acute and mean people go straight to hospital if they get them.

Only a small minority of brain tumours start with headache as a first symptom - patients are more likely to experience a sudden fit, reduced coordination and visual problems that get progressively
worse.

The guidelines will also focus on ensuring appropriate treatment options are discussed, highlighting that in some cases medication overuse could be the underlying cause of headaches.

Dr Steve Mowle, The Royal College of GP's vice chair, says GPs see tension headaches and migraines most often, which can usually be treated with over-the-counter medications such as paracetamol or
ibuprofen.

However, he points out: "Some patients remain anxious that their headache is actually the symptom of something more serious."

This can especially be the case for migraine sufferers - a condition that can be extremely debilitating.

Joanna Hamilton-Colclough, director of the charity Migraine Action, says: "Most people who have migraine need reassurance that with help and support the symptoms can be managed, so the relationship
between the GP and the patient is of utmost importance."

Many patients try to manage headaches on their own, she says, and when they do go to the GP "they're often not speaking the same language".

She explains: "Doctors are looking for patients to understand their symptoms in order that they can make an accurate diagnosis. The patient is seeking reassurance that they don't have a brain
tumour."

If this sounds familiar, hopefully next time you visit your GP about a headache, your worries will be eased.

"Hopefully one outcome of the new guidelines will be that in the eyes of the medical profession, headache is seen as a real condition and is given more attention," says Dr Dowson.

"This can only be positive for headache patients."

If you're worried about your headaches, they could be one of the following: Tension-type headache This is the most common type, and causes the low-grade, dull ache which most people have
experienced. They often feel like constant pressure around the front, top and sides of the head as if a rubber band has been stretched around it, and are more frequent in women than men.

While the exact cause of tension headaches isn't clear, they can be triggered by many lifestyle factors, including stress, drinking too much alcohol, poor sleep, depression, skipping meals,
menstrual periods and becoming dehydrated. Physical tension such as poor posture or squinting to read can cause scalp or neck muscles to tense up, which can also lead to a tension-type headache.
Approximately 3% of people have chronic tension-type headaches, experiencing symptoms on most days.

They are usually successfully treated with over-the-counter painkillers such as paracetamol or ibuprofen. Addressing any underlying lifestyle factors is also crucial.

Cluster headaches These tend to happen in clusters (hence the name) for a month or two at a time, around the same time of year. They're much less common than tension headaches and are thought to
occur in just 0.1% of the population.

Nicknamed 'suicide headaches' or 'alarm clock headaches' because of the excruciating pain they cause, they normally affect one side of the head around the eye, and sometimes the temples and cheeks.
Sufferers will often pace the room, rock, or bang their head against a wall because the attacks are so painful.

They can occur up to eight times a day for between 15 minutes and three hours, every day for months, followed by a pain-free period which can last months or years before the headaches start again.

It's not known what causes cluster headaches, but they're more common in autumn and spring, and they can sometimes be triggered by drinking alcohol or an extreme increase in temperature.

Pharmacy medications don't ease the symptoms of a cluster headache, but a doctor can prescribe specific treatments to ease the pain, and oxygen therapy (breathing in oxygen through a mask) may also
help.

Migraines If a headache is recurrent and stops you from carrying on with your life as normal, it may be a migraine. They occur in around one-in-four women and one-in-12 men in the UK, and can start
suddenly at any age. They often feature a throbbing headache, which may be one-sided, feeling or being sick, lethargy, and light and sound sensitivity, although not all sufferers have every
symptom.

About a third of people with migraines have warning symptoms, known as aura, beforehand. These can include seeing flashing lights, having difficulty speaking, or feeling a tingling sensation.

Migraines are thought to be caused by changes in the chemicals of the brain, and they have a variety of triggers which include emotional, physical, dietary, environmental and medicinal factors.

Over-the-counter medication can help ease the pain of a migraine, but severe migraines may benefit from stronger migraine-specific medication prescribed by a doctor.